Evaluating the design and implementation fidelity of an adapted Plan-Do-Study-Act approach to improve health system performance in a Nigerian state

BackgroundThe Plan-Do-Study-Act (PDSA) cycle is fundamental to many quality improvement (QI) models. For the approach to be effective in the real-world, variants must align with standard elements of the PDSA. This study evaluates the alignment between theory, design and implementation fidelity of a PDSA variant adapted for Nigeria’s health system performance improvement.MethodsAn iterative consensus building approach was used to develop a scorecard evaluating new conceptual indices of design and implementation fidelity of QI interventions (design and implementation index, defects and gaps) based on Taylor’s theoretical framework.ResultsDesign (adaptation) scores were optimal across all standard features indicating that design was well adapted to the typical PDSA. Conversely, implementation fidelity scores were only optimal with two standard features: prediction-based test of change and the use of data over time. The other features, use of multiple iterative cycles and documentation had implementation gaps of 17 % and 50 % respectively.ConclusionThis study demonstrates how both adaptation and implementation fidelity are important for success of QI interventions. It also presents an approach for evaluating other QI models using Taylor’s PDSA assessment framework as a guide, which might serve to strengthen the theory behind future QI models and provide guidance on their appropriate use.     

Health outcomes for adults in family foster care as children: An analysis by ethnicity

Studies have linked the experience of child abuse or adversity to health problems in adulthood, and researchers have long documented health problems affecting children in foster care. Yet, the adult health outcomes of maltreated children placed in foster care have not been sufficiently isolated. Although information on transitioning youth and young adults is now beginning to emerge, the impact of ethnicity on adult health outcomes has been largely ignored. Given the overrepresentation of ethnic minority children in foster care and the national disparities in the health of ethnic minorities, this study examined the relationship between ethnicity and physical health outcomes for African American, Hispanic, and White adults who experienced family foster care as children. Logistic regression models indicated that ethnicity was not a significant predictor of physical health (p > .05). However, gender and age were associated significantly with their physical health outcomes.     

An innovative medical and dental hygiene clinic for street youth: Results of a process evaluation

Canada has a noteworthy reputation for high quality health care. Nonetheless, street youth are one of our most vulnerable yet underserved populations. Consequently, a medical and dental clinic was created in downtown Ottawa, Ontario to respond to their needs. The purpose of this study is to describe a process evaluation of the clinic during its first year of operation with a focus on program fidelity, dose, reach, and satisfaction. A mixed methods approach was used involving interviews with providers, focus groups with street youth, analysis of Electronic Medical Record (EMR) data, and supplemental information such as document reviews. The evaluation identified areas that were working well along with challenges to program implementation. Areas of concerns and possible solutions were presented to the management team that then helped to plan and make improvements to the clinic. Our evaluation design and working relationship with clinic management promoted the integration of real-time evidence into program improvements.     

Dealing with context in logic model development: Reflections from a realist evaluation of a community health worker programme in Nigeria

Logic models (LMs) have been used in programme evaluation for over four decades. Current debate questions the ability of logic modelling techniques to incorporate contextual factors into logic models. We share experience of developing a logic model within an ongoing realist evaluation which assesses the extent to which, and under what circumstances a community health workers (CHW) programme promotes access to maternity services in Nigeria. The article contributes to logic modelling debate by: i) reflecting on how other scholars captured context during LM development in theory-driven evaluations; and ii) explaining how we explored context during logic model development for realist evaluation of the CHW programme in Nigeria. Data collection methods that informed our logic model development included documents review, email discussions and teleconferences with programme stakeholders and a technical workshop with researchers to clarify programme goals and untangle relationships among programme elements. One of the most important findings is that, rather than being an end in itself, logic model development is an essential step for identifying initial hypotheses for tentative relevant contexts, mechanisms and outcomes (CMOs) and CMO configurations of how programmes produce change. The logic model also informed development of a methodology handbook that is guiding verification and consolidation of underlying programme theories.     

Rural homelessness: its effect on healthcare access,healthcare outcomes,mobility, and perspectives of novel technologies

Rural homelessness is an undeniable public health issue that is understudied in the research literature. The purpose of this study was to determine the sociodemographics, physical and mental health status, barriers to access to care, and perspectives on potential technological advances of homeless individuals. A structured 45–90?min interview was utilized to gather demographic, physical health, mental health, mobility, and technology use data from a sample of 75 homeless individuals within three shelters in three micropolitan Nebraska cities. Individuals in this region were more likely to be white, unmarried, and mobile who have various physical and mental health disorders. Adherence to treatment of mental health disorders ranged from 43–60 percent. This population had increased employment, access to healthcare services, and use of technology than predicted. Leaders from all over the country can use these data to help improve state and local efforts to better cater to this vulnerable population's needs.     

Integrating Sexual Health Services Into Primary Care: An Overview of Health Systems Issues and Challenges in Developing Countries

ABSTRACT

Current attempts to address the high burden of sexual health morbidity and mortality in developing countries remain limited in scale due to a range of health system constraints. We conducted a literature review of the policy and programmatic issues that influence the integration of sexual health into primary care services in developing countries. Forty-seven reports were identified from a search of both peer-reviewed and gray literature. Key issues identified were intersectoral and intergovernmental coordination; management and organizational issues including decentralization, health sector reform, logistics, and referral systems; human resources, including training and support required to increase service scope; relationships between the public and private sectors; and scaling-up and financing issues.     

An overview of concept mapping in Dutch mental health care

About 25 years ago, concept mapping was introduced in the Netherlands and applied in different fields. A collection of concept mapping projects conducted in the Netherlands was identified, in part in the archive of the Netherlands Institute of Mental Health and Addiction (Trimbos Institute). Some of the 90 identified projects are internationally published. The 90 concept mapping projects reflect the changes in mental health care and can be grouped into 5-year periods and into five typologies. The studies range from conceptualizing the problems of the homeless to the specification of quality indicators for treatment programs for patients with cystic fibrosis. The number of concept mapping projects has varied over time. Growth has been considerable in the last 5 years compared to the previous 5 years. Three case studies are described in detail with 12 characteristics and graphical representations. Concept mapping aligns well with the typical Dutch approach of the “Poldermodel.” A broad introduction of concept mapping in European countries in cooperation with other countries, such as the United States and Canada, would strengthen the empirical basis for applying this approach in health care policy, quality, and clinical work.     

Implementation of a Collaborative Care Initiative for PTSD and Depression in the Army Primary Care System

Collaborative care models hold promise as a means to improve the Military Health System (MHS) to better meet the mental health needs of U.S. military personnel. This article describes an Army-wide collaborative care initiative, RESPECT-Mil (“Re-engineering Systems of Primary Care Treatment for Depression and PTSD in the Military”), aimed at improving care for soldiers with depression and post traumatic stress disorder. Essential to the implementation of RESPECT-Mil has been the use of a centralized coordinating team to facilitate collaborative care practice and policy activities across the multiple levels of the MHS. The article explores the relevance of collaborative care frameworks to the social work profession and concludes with a discussion of future directions for the social work field to promote greater involvement in the integrated care movement.     

Parental style,parental practices,and socialization outcomes: An investigation of their linkages in the consumer socialization context

This study aims to generate insights into the mechanisms through which parental style influences adolescent consumer socialization. Toward this end, it examines two alternative conceptual frameworks: (1) The mediation model which posits two key dimensions of parental style (responsiveness and demandingness) as antecedent variables affecting adolescent consumer socialization directly and indirectly through parental socialization practices and (2) the moderation model which posits each parental style dimension as a moderator of the link between parental socialization practices and adolescent socialization outcomes. The influences of maternal and paternal parental styles on adolescent socialization outcomes are investigated separately and compared. Results provide stronger support for the mediation model. They also show that mothers’ parental style and practices are more influential than fathers’ in shaping adolescents’ consumer socialization outcomes.     

Inequities in health outcomes and access to health care in South Africa: a comparison between persons with and without disabilities

Health is a fundamental human right and if health care is to be universal and equitable it should not be less accessible to some sectors of society than to others. The objective of this study was to compare health outcomes and access to health care between persons living with disabilities and their non-disabled counterparts. The research was based on secondary data analysis of wave 1 of the National Income Dynamic Survey. Results from the study indicated that people with disabilities reported a higher incidence of communicable and non-communicable diseases, lower access to medical insurance and greater use of public health care than their non-disabled counterparts. In conclusion, the findings highlight the inequities in health outcomes and access to health services for people with disabilities and emphasise the need for disability-friendly health care policies that reduce barriers to accessing health care.     

Causal relationships between background characteristics, service utilization, satisfaction, and service outcomes (school performance): A path analysis

This study develops a causal model to examine the relationships between service outcome (school performance) and consumer satisfaction, service utilization, and demographic characteristics of the youth receiving mental health services. Data for 281 children, aged 12–18, served from April 2003 to December 2004 were used for the analyses. Causal relationships among variables of the proposed model were tested by using AMOS, and the respecified model was accepted as the final model with good fit to the data (2 = 5.099, df = 8, NFI = .951, CFI = .998, RMSEA = .001). Results of the model test point to the importance of the children's age, service intensity, and consumer satisfaction as determinants of school performance outcome. In particular, increased worker satisfaction and overall satisfaction lead to increases in the perceived success satisfaction and this satisfaction, in turn, leads improvement in grades. Efforts to improve service satisfaction are emphasized and studies based on a more dynamic perspective are needed.     

Using the evaluation process as a lever for improving health and healthcare accessibility: The case of HCV services organization in Quebec

BackgroundThe evaluation process can be a lever to improve pathways of access to healthcare. The objective of this article is to show how an evaluation strategy can both contribute to knowledge development and have direct impacts on health services provision. We use the case of hepatitis C (HCV) services organization to illustrate the use and the value of this evaluative approach.MethodInspired by empowerment evaluation, the transformative–participatory approach involved overlapping phases of knowledge development and discussion with stakeholders. We conducted several knowledge development activities to discern the needs of people with HCV, the resources available, and the facilitators and impediments along the care pathway, starting from prevention and screening, all the way through to treatment. Using an overlapping approach allowed us to regularly transfer acquired knowledge back to the participants in the study settings and also to gather their impressions, interpretations, and suggestions during periods of deliberation.ResultsThe knowledge development activities made it possible to document the needs, resources, and experiences of people affected by HCV. In the discussion sessions, viable solutions were identified to improve health and healthcare access for people with HCV and to prioritize certain actions. This project demonstrated that using the evaluation process can enable an instrumental, conceptual use of results and, in fact, can have a transformative impact on services organization.     

Evaluating complex interventions in real context: Logic analysis of a case management program for frequent users of healthcare services

Case management programs for frequent users of healthcare services are complex interventions which implementation and application are challenging to evaluate. The aim of this article was to conduct a logic analysis to evaluate a case management program for frequent users of healthcare services. The study proceeded in three phases: 1) establishing causal links between the program’s components by the construction of a logic model, 2) developing an integrated framework from a realistic synthesis, and 3) making a new reading of the case management program in regard of the integrated framework. The study demonstrated, on one hand, strengths and weaknesses of the actual case management program, and, on the other hand, how logic analysis can create a constructive dialogue between theory and practice. The evaluative process with decision-makers, clinicians and patients has helped to make connexions between theory, practice, experience and services organization.     

Developing a public health policy-research nexus: An evaluation of Nurse Practitioner models in aged care

A frustration often expressed by researchers and policy-makers in public health is an apparent mismatch between respective priorities and expectations for research. Academics bemoan an oversimplification of their work, a reticence for independent critique and the constant pressure to pursue evaluation funding. Meanwhile, policy-makers look for research reports written in plain language with clear application, which are attuned to current policy settings and produced quickly. In a context where there are calls in western nations for evidence based policy with stronger links to academic research, such a mismatch can present significant challenges to policy program evaluation. The purpose of this paper is to present one attempt to overcome these challenges. Specifically, the paper describes the development of a conceptual framework for a large-scale, multifaceted evaluation of an Australian Government health initiative to expand Nurse Practitioner models of practice in aged care service delivery. In doing so, the paper provides a brief review of key points for the facilitation of a strong research-policy nexus in public health evaluations, as well as describes how this particular evaluation embodies these key points. As such, the paper presents an evaluation approach which may be adopted and adapted by others undertaking public health policy program evaluations.     

Primary Care Screening of Depression and Treatment Engagement in a University Health Center: A Retrospective Analysis

Abstract

Objectives: This retrospective study analyzed a primary care depression screening initiative in a large urban university health center. Depression detection, treatment status, and engagement data are presented. Participants: Participants were 3,713 graduate and undergraduate students who presented consecutively for primary care services between January and April 2006. Methods: A standardized 2-tiered screening approach for an inception cohort of students utilizing primary services. Primary care providers were trained to triage students with depressive symptoms. Results: Six percent of participants had clinically significant depressive symptoms (CSD). Severe depressive symptoms were found in less than 1.0% of participants. Male rates of severe depressive symptoms were more than double that of females. Only 35.7% of untreated depressed participants started treatment within 30 days following identification. Conclusions: Systematic primary care depression screening in a college health center is a promising approach to identify untreated students with depression. More study is needed to improve rates of treatment engagement.     

The African Evaluation Guidelines: 2002. A checklist to assist in planning evaluations, negotiating clear contracts, reviewing progress and ensuring adequate completion of an evaluation

A review of the US ‘program evaluation standards’ (PES), undertaken in a series of workshops and meetings of networks of evaluators in Africa, resulted in modifications to those standards. The result was presented to a plenary session of the Inaugural Conference of the African Evaluation Association in September 1999, attended by over 300 evaluators from 35 countries. The AfrEA Conference decided that a systematic effort should be made to produce a list of African evaluation guidelines, similar to the PES, and that this checklist should be reviewed by national evaluation associations and networks in Africa and field tested in several countries. Ten national and regional networks and associations suggested modifications to the text and endorsed the final version of the guidelines.     

Understanding of elder abuse and neglect among health care professionals in Malaysia: An exploratory survey

ABSTRACT

Elder abuse and neglect (EAN) is a hidden public health challenge for Malaysia. This cross-sectional survey studied the awareness of EAN among 148 doctors and nurses from two neighboring states in Malaysia using a self-administered questionnaire exploring their knowledge, perceptions, practices, and experience concerning EAN. Both doctors and nurses demonstrated poor understanding of signs of EAN and exhibited misperceptions on reporting requirements. Both groups perceived EAN as a national burden and reporting it as their responsibility; but most felt they had not been trained to diagnose it. Many were unsure of procedures and whether their own intervention could be effective. Only four (nurses) of 41 participants who suspected abuse during the past year reported the cases. Targeted education and uniform protocols are mandatory to ensure best practice with regards to EAN. Further research is crucial to extend this inquiry into the broader health care workforce.     

Conservation of Resources theory in the context of multiple roles: an analysis of within- and cross-role mediational pathways

Based on the Conservation of Resources theory, we used data from the National Survey of Midlife Development in the United States (MIDUS I, 1995–1996; N=1779) to estimate by covariance structure analysis the direct and indirect effects of work and family demands, resources, and support on psychological distress. In a new application of the theory, we estimated six within-role mediational pathways linking work-related predictors to psychological distress through work interfering with family (WIF) and family-related predictors to psychological distress through family interfering with work (FIW). Finally, in a departure from previous work–family research, we estimated six cross-role mediational pathways linking work-related predictors to psychological distress through FIW and family-related predictors to psychological distress through WIF. Ten of the 12 hypothesized mediational effects were significant and another was marginally significant, supporting the mediational role of work–family conflict within Conservation of Resources theory.